The Opioid epidemic that has so devastated America is now well established in Australia.
As I write comes the following news from the US. President Trump, hearing from aides that his plan to accept the advice from health experts that flavoured E cigarettes should be banned would cost him votes, reversed his decision to support this urgent health initiative. Last week a 17 year old boy in the US needed a double lung transplant following the use of E cigarettes. Trump’s reign has been a disaster for health care in the US as he endorses suspicions that vaccines do more harm than good, strips 26 million people of health insurance because the scheme that protected them started with the letters Obama, strips the National Institutes of Health and its world leaders in research of an adequate budget and ignores climate change and its associated health hazards. Given the above it is perhaps predictable that his administration is allowing drug companies, whose misleading, indeed fraudulent promotion of opioids caused thousands of deaths in the US, to pay compensation to victims and their families, without the need to accept and acknowledge any blame for their unconscionable behaviour. These companies are big political donors and buy their influence.
In the early part of my career, as was true of most doctors I think, I had the greatest respect and admiration for the drug companies that were producing so many drugs which saved and/or improved so many lives. In recent decades however numerous scandals have been generated around scandalous behaviour from even the biggest and most respected companies such as Eli Lilly, Amgen and Abbott. Until recently, perhaps the most notorious case of irresponsible, indeed deadly fraud, involved Glaxo Smith Kline (GSK) one of the worlds pharmaceutical giants. In summary, GSK thought they had a drug (Paroexitine) that would be of major benefit in the treatment of severe adolescent depression. A large clinical trial found that the drug did not work. Worse, it resulted in many, suicidal ideation and even suicide. Incredibly GSK, instead of publishing the negative results, hired a writer to produce a paper showing great results and a high level of safety. They then found 22 doctors, supposedly experts in the field, whom they paid to provide “ringing endorsements” on the basis of what they were told. They did not bother to examine the research data. GSK was fined 3 billion dollars when the fraud was revealed.
The above scandal and the harm done was nothing compared to the most recent reprehensible behaviour by drug companies which has resulted in the epidemic overuse of opioids in the US causing as many as 50,000 deaths a year and much suffering among those addicted. The opioids are drugs that act on the brain to suppress pain. (Sometimes referred to as “Narcotics”). Most were created by extracting the responsible chemicals from Poppies though some can now be produced in a laboratory from scratch. Heroin is an example of the former and Fentanyl, of which more below, is an example of the latter. Most commonly however the formulation most used is in tablet form and known as Oxycodone marketed as OxyContin. In Australia, a much weaker opioid, codeine, has been available as an “over the counter” medication until recently. The opioids are powerful pain suppressors but they change cellular behaviour among certain brain cells that results in the cells needing opioids for their function. When opioids are not available the stressed cells actually aggravate pain. This biological demand is the basis of addiction.
Now the root causes of the epidemic which, as we will discuss, is now entrenched in Australia as well as a number of other countries besides the US, are two fold. We have throughout the western world ever increasing numbers of individuals who suffer from severe and chronic pain and health systems the are failing to adapt to help such patients without using narcotics. Arthritis, cancer, post trauma pain, post surgical pain and any number of other conditions including occasionally, psychiatric conditions, can produce excruciating pain. The irony is that while the short term relief of pain with opioids was tempting but dangerous, pain specialists were making great strides in the development of non narcotic measures to satisfactorily control chronic pain. The availability of such advances however in specialised “pain clinics” was and, though improving in Oz, is a major problem Not surprisingly then our opioid addiction is worse among economically deprived Australians, especially indigenous ones.
Back to the US Epidemic and the scandalous behaviour of the marketers of OxyContin. Two companies stand out as the major offenders, Purdue Pharma and Johnson and Johnson (with the oh so wholesome Baby powder image) who both paid representatives to peddle their oxycodone to doctors as drugs that were not addictive and certainly not killers while claiming that their companies’s products were superior. The companies ran courses in pain management and paid doctors handsomely to attend. Here the emphasis was on using OxyContin for pain control. The result was the loss over a decade or so of 400,000 American lives. Regulatory weakness in America linked to the the payment of 2.5 billion dollars to fund hundreds of lobbyists and pay off members of congress was a major facilitator. This may explain how it was that in 2007, after Purdue pleaded guilty to a federal crime of lying in an aggressive marketing campaign, they were able to subsequently proceed with the same irresponsible marketing. In 2012 US doctors wrote 255 million prescriptions for narcotics. Recent evidence suggest that the Food and Drug Administration (FDA) Commissioners in the US were “paid off” by the opioid marketers and this explains their approval year after year of ever more powerful narcotics. This included the drug, Fentanyl, which is 100 times more potent than morphine. So high was the demand for this drug by those addicted that the Mexican drug cartels became major suppliers.
Our opioid epidemic is as real and entrenched, if of a lesser magnitude than the one described for the US. In 2015, 15 million opioid prescriptions were dispensed in Australia. It is estimated that 750,000 Australians may be addicted. This addiction to OxyContin kills many more of us than does Heroin. Last year 1123 of us died from using opioids with accidental overdose being a very common cause. This represents a marked increase in deaths related to opioid use which were in the 400 a year range a decade ago. Again, sad to say, many Australian doctors have allowed financial and other inducements from drug company to influence their prescribing habits. The international arm of the American company Purdue, regarded as the main offender in the causation of the US epidemic, Mundipharma, has been much criticised for its marketing tactics in promoting its OxyContin in Australia.
What can we do to blunt this epidemic which the NSW Coroner recently opined would kill thousands of Australians over the next few years without the implementation of needed reforms. Prescription tracking is one of the needed reforms. Doctor shopping has seen addicts visit multiple doctors obtaining multiple prescriptions. Plenty of overdose deaths have been related to the ready availability of large amounts of OxyContin. The Federal government promised a national tracking system for opioid prescriptions by the end of 2018 to help. Identify patients attempting to have multiple prescriptions dispensed but to date nothing has materialised.
The whole question of how doctors interact with the pharmaceutical industry needs close examination and is a huge topic for another time. Certainly we must increase the availability of access to multidisciplinary pain services. This is crucial but so too is the better education of doctors particularly our GPs in ways of handling chromic pain and opioid dependence so that treatment can start while waiting for access to specialist pain management clinics. The 57 pain clinics recognised across Australia also need to increase their skills in managing established addiction problems. Currently only four clinics have this dual capacity. Only a few multidisciplinary pain clinics, when available, offer treatment paid for by Medicare and this must change as it is the economically disadvantaged who need the services the most. It is possible to combine anti-addiction drugs such as Naloxone with opioid preparations and much more research is needed to see if the combination will prevent the neurological changes that produce addiction. Patients and often GPs are reluctant to try Methadone as part of a treatment regimen for established addiction because of the stigma associated with a drug traditionally used to treat heroin addiction, this despite the evidence that it can provide considerable benefit.
It is important for doctors and their patients to understand that there is a necessary and constructive role for opioid medications in short-term pain management. Banning these medications is not the answer. The issues discussed here are so serious and contemporary that we need to gather the appropriate experts together to produce a multi-faceted “National Strategy” that would see us co-ordinate a nation wide program appropriately funded by government. Such a need is urgent and should be a top priority for our COAG Heath council to insure that any program is endorsed by all States and the Commonwealth. This is the tragic epidemic we didn’t need to have and must terminate. Doing so will be expensive in dollar and human resource terms but nothing like as expensive as having more and more Australians crippled with pain and unable to function constructively in our community. What a blessing would be a national program that ended the epidemic and made effective, safe pain control available to all that need it.
Professor John Dwyer, Emeritus Professor of Medicine UNSW and founder of the Australian Healthcare Reform Alliance.